Congenital stromal corneal dystrophy in a Spanish family: Clinical, genetic and histological analysis

PURPOSE

To present the clinical, genetic, and histopathological features of the ninth family affected by congenital stromal corneal dystrophy (CSCD) to date.

METHODS

Twelve cases of a Spanish family affected by CSCD were analyzed regarding history, visual acuity (VA, decimal scale), an ophthalmologic exam and specular microscopy. Five eyes were treated by deep anterior lamellar keratoplasty (DALK), and thirteen eyes by penetrating keratoplasty (PK). In the two last generations, a genetic study was performed.

RESULTS

Most of the patients affected were born with opaque corneas except for three, whose corneas were clear at birth. Biomicroscopy showed a whitish diffuse stromal opacity with an unaltered epithelium, causing poor VA (from hand motions to 0.4). Patients treated with PK presented mean postoperative VA of 0.19±0.20 over a follow-up time of 235.3±101.4months with 38% recurrences. Patients who underwent DALK experienced VA improvement to 0.17±0.11 over a follow-up time of 10.8±2.6months without signs of recurrence. In the latter, the big bubble technique was not achieved, so a manual technique was performed. The genetic study showed heterozygosis for a 1-bp deletion at nucleotide 962 in exon 8 of the decorin gene.

CONCLUSIONS

CSCD is a rare entity, which should be treated by DALK whenever possible, obtaining better results than PK. Close monitoring of children of affected individuals is important, because CSCD can progress during the early years of life.

Detection and characterisation of visual field defects using Octopus perimetry in congenital glaucoma

PURPOSE

To detect and characterise visual field (VF) defects using static Octopus perimetry in patients with primary congenital glaucoma (PCG) and to determine VF quality and time duration.

MATERIAL AND METHODS

Eighty-eight eyes of 70 patients diagnosed with PCG were included. Assessments were performed using an Octopus 900 and each eye was assessed with the tendency-oriented perimetry (G-TOP) algorithm. Quantitative VF data were collected: quality data (false positive and negative response, and time duration) and results of mean deviation (MD) and square root of loss variance (sLV). Qualitative data were collected: the presence of diffuse and localized defects, the affected hemifield and grade of defects using the Aulhorn and Karmeyer classification. Correlations between perimetric results and clinical variables were analysed.

RESULTS

Median age was 11 (8-17) years. 65.9% (58/88) of PCG eyes showed VF defects. Diffuse defects were observed in 10/58 eyes (16.94%) (mean MD = 23.92 [SD: 2.52]) dB) and localized defects in 48/58 eyes (82.75%). The most frequent defect was spot-like/stroke-like/incipient paracentral scotoma (n = 15), nasal step (n = 8), adding arcuate defect (n = 2), half ring-shaped (n = 13) and concentric defect with a central island (n = 9). And the most frequent affected visual hemifield was inferior hemifield. Mean test duration was 2 min 12 s (SD: 21.6 s). MD and sLV values were correlated with best corrected visual acuity (BCVA), cup to disc ratio and number of antiglaucoma surgeries (all P < .001).

CONCLUSION

A high number of diffuse and localized defects were identified using Octopus perimetry in PCG patients. The most frequent defect was paracentral scotoma and inferior hemifield was the most affected.

Corneal endothelial validation in the eye bank: differences in automated methods and repeatability

PURPOSE

To evaluate reproducibility of endothelial cell density (ECD) measurements using the Konan Cell Check D in donor corneas by two different ophthalmologists and to compare the two automated cell count methods (center and flex-center) available in the software of this specular microscope.

METHODS

ECD values were quantified in 54 donor corneas by two independent investigators using the Cell Check D (Konan Medical USA Inc) with both automated cell count methods. In the center method, at least 30 contiguous cells are marked. For the flex-center method, an area is delineated and only the cells within the designated area are counted.

RESULTS

The mean ECD was 2473.81±378.22 cells/mm2. Good ECD intergrader reproducibility for the center (ICC=0.821) and the flex-center method (ICC=0.784) were noted. Poor reliability was observed for coefficient of variation and hexagonality (ICC≤0.265). When both methods for ECD analysis were compared, a moderate correlation for the two independent graders using the two manual (center and flex-center) methods was detected (correlation coefficient of 0.678 and 0.745 for each of the investigators). Comparison between methods yielded significantly higher ECD with the flex-center method (P=0.013). When corneas were divided by ECD, those under 2200 cells/mm2 and those between 2200 and 2700 cells/mm2 also had significantly higher ECD with the flex-center method (P<0.022).

CONCLUSIONS

ECD values are reproducible with both methods, although the flex-center method ECDs tend to be higher, particularly in cases of low ECD. Eye banks and surgeons should exercise caution in making decisions based only on small differences in ECD.

POS1355 TO COMBINE OR NOT TO COMBINE: INFLUENCE OF IMMUNOSUPPRESSIVE DRUG COMBINATION IN THE INDUCTION OF THERAPEUTIC RESPONSE IN NON-INFECTIOUS UVEITIS

Background

Non-infectious uveitides (NIUs) include a heterogeneous group of sight-threatening and incapacitating conditions. Their correct management sometimes requires the use of immunosuppressive drugs (ISDs), prescribed in monotherapy or in combination. Several observational studies showed that the use of ISDs in combination could be more effective than their use in monotherapy. However, a direct comparison between these two treatment strategies has not been carried out yet.

Objectives

To analyze the effect of ISDs combination therapy (CT) on the response rate in patients with NIUs.

Methods

Patients attending a Uveitis Outpatient Clinic from a tertiary care center in Madrid, Spain, and prescribed with ISDs from 1991 to 2018 were included. Patients were assigned as controls or cases based on whether they were prescribed with ISDs in monotherapy (MT) or CT. ISD treatment changes during the observation period were also considered. The primary outcome was good therapeutic response (GTR), defined as the complete resolution of the eye inflammatory manifestations and oral corticosteroid dosage ≤10 mg of prednisone equivalent a day. Furthermore, this situation had to be maintained in at least two consecutive visits spanned at least 28 days. Several propensity score based and non-based weighting techniques for data balancing, followed by Cox regressions, were performed to estimate the effect of CT on the response rate. Random forest (RF) models and clinical appraisal were used to select the variables to be balanced.

Results

100 episodes of ISD prescription belonging to 73 patients were included in this analysis. In 32 episodes, patients were prescribed with CT (in 3 episodes CT was the initial therapeutic strategy; in 29, combination was the result to adding a second or third ISD). The most frequent drug used in MT was cyclosporine A (CYA; n=39), and the most frequent CT was synthetic + biological ISD (n=21). After RF, the number of previously used ISDs, the prescription of CYA, the dosage of oral corticosteroids at prescription, a previous ISD withdrawal due to inefficacy, and duration of disease were selected for balancing. In addition, after clinical appraisal, uveitis diagnosis, prescription with azathioprine, prescription with methotrexate, and eye activity features at prescription (presence of cells in anterior chamber, vitreous haze, macular edema, active chorioretinal lesions) were also balanced. The Energy balancing method showed the best balance for GTR. After Cox-regression, CT prescription did not show a statistically significant effect in the hazard of response (p=0.43; Table 1).

Table 1.

Cox models showing the effect of combination therapy in the hazard of good therapeutic response after balancing covariates using the Energy method.

VariableHR (95% CI)p valueSchoenfeltest p valueCombination Therapy0.66 (0.24-1.83)0.430.82Cyclosporine A prescription3.36 (1.22-9.27)0.0190.96Methotrexate Prescription2.20 (0.72-6.71)0.160.95Presence of cell in anterior chamber1.75 (0.83-3.72)0.140.89

Conclusion

The use of CT in our study was not associated with a better therapeutic response in NIU patients compared with the prescription of MT. Considering that most CT episodes were the result of the addition of a new ISD in a patient already treated and still active, the effectiveness of CT as the initial therapeutic strategy remains unanswered.

Disclosure of Interests

None declared

POS1354 ANALYSIS OF FACTORS ASSOCIATED WITH GOOD THERAPEUTIC RESPONSE TO IMMUNOSUPPRESSIVE DRUGS IN PATIENTS WITH NON-INFECTIOUS UVEITIS: A SURVIVAL ANALYSIS

Background

Non-infectious uveitides (NIUs) encompass a varied group of inflammatory diseases affecting the uvea and adjacent tissues, with evidence suggesting an immune-mediated cause. A correct management of these conditions is essential to prevent substantial and sometimes permanent visual loss and the development of ocular complications. Although immunosuppressive drugs (ISDs) have shown effectiveness in achieving a sustained control of the inflammatory process, not all patients achieve a satisfactory response.

Objectives

To identify factors affecting the response rate to ISDs in subjects with NIUs.

Methods

Longitudinal retrospective study, with patients collected from the Hospital Clinico San Carlos Uveitis Clinic, included from 1991 until December 2018, and followed-up until December 2019. Patients entered the study at ISD prescription and were followed-up until a) the achievement of a good therapeutic response (GTR), b) ISD treatment change (withdrawal of the prescribed ISD and/or addition of a new ISD), c) 12 months of follow-up, or d) loss of follow-up or end of the study (December 31th, 2019). GTR was defined as the complete resolution of the eye inflammatory manifestations and oral corticosteroid ≤10 mg of prednisone equivalent a day. Furthermore, this situation had to be maintained in at least two consecutive visits spanned at least 28 days. Kaplan-Meier (KM) curves were set to account for GTR. Associated demographic, clinical and treatment-related factors were analyzed using bivariate and multivariate Cox robust regression models. Different models were compared using the Akaike Information Criteria, to select the fittest model to the data. Proportional hazard assumption was tested using Schoenfeld residuals and the scaled Schoenfeld residuals. In case a variable or certain category of a categorical variable were non-proportional, they were included in the Cox models with a time-varying effect, in case the interaction with time was significant (p<0.05).

Results

73 patients (100 episodes of ISD prescription) were analyzed. In 44 episodes, a GTR was achieved (incidence rate 102.0 [95% Confidence Interval (CI): 75.9 to 137.1] per 100 patient-years). Figure 1 shows the KM curve for GTR. In the bivariate analysis, several variables showed a significant association with GTR, including gender, diagnosis of Behçet Disease, prescription of Cyclosporine A (CYA), number of previously prescribed ISDs, previous use of the same ISD, previous discontinuation of a ISD due to inefficacy, higher systemic corticosteroid use in the previous year before ISD prescription, presence of macular edema (ME), and longer intermediate and posterior activity before ISD prescription. Table 1 shows the results of the multivariate analysis. Prescription of CYA was associated with a higher hazard of GTR, compared with the use of other ISDs (methotrexate, azathioprine or biologic drugs). In addition, the higher dosage of oral corticosteroids used in the previous year before ISD prescription, the lower the hazard of achieving a GTR. Finally, presence of ME at prescription was associated with lower hazard of GTR, although this risk diminished with time.

Table 1.

Multivariate Cox robust regression to analyze variables independently associated with the achievement of good therapeutic response.

VariableHR (95% CI)p valueSchoenfel test p valueCYA prescription2.04 (1.14-3.67)0.0170.56Number of previous ISDs0Reference--112.61 (2.07-76.73)5.9x10-30.001≥23.54 (1.55-8.05)2.6x10-30.561 previous ISD X Time0.01 (0.001-1.00)0.005Higher oral corticosteroids dosage (mg) in the previous year0.98 (0.97-0.99)0.0130.83Macular edema0.14 (0.04-0.45)9.3x10-30.001Macular edema X Time14.20 (1.55-103.10)0.019Figure 1.

Kaplan-Meier failure curves representing good therapeutic response after immunosuppressive drug prescription for non-infectious uveitis.

Conclusion

We have identified several variables associated with therapeutic response to ISDs in NIUs patients.

Disclosure of Interests

None declared

Comparison of corneal biomechanical properties of patients with dry eye secondary to Sjögren's syndrome and healthy subjects

PURPOSE

The goal of this study is to determine whether any difference in corneal biomechanical properties exists between Sjögren's syndrome dry eye patients and healthy subjects.

METHODS

Thirty-one patients diagnosed with Sjögren's syndrome and associated dry eye manifestations and 44 healthy individuals were included in the study. Ultrasonic pachymetry (UP) was used to measure central corneal thickness (CCT). Corneal biomechanical parameters were obtained using ocular response analyzer (ORA). The main parameters assessed were corneal hysteresis (CH), corneal resistance factor (CRF), Goldmann correlated intraocular pressure (IOPg) and corneal compensated IOP (IOPcc). A Student's t-test for independent groups was performed to compare the mean of these variables between both groups.

RESULTS

Mean CH values in Sjögren's syndrome and healthy subject eyes were 10.1mmHg and 11.18mmHg respectively, representing a statistically significant difference (P=0.003). No other variable measured differed between cases and controls (P>0.05). Mean CRF values were 9.51mmHg and 10.37mmHg respectively, and mean CCT measured by UP in cases and controls was 527.41μm and 552.51μm respectively.

CONCLUSIONS

Sjögren's syndrome can influence corneal biomechanical properties, specifically CH. ORA measurements should be considered of interest in the evaluation of Sjögren syndrome subjects.

Retinal venous thrombosis in a young patient with coagulation factor XII deficiency

CASE REPORT

A 35-year-old woman, with no relevant medical history, was referred for sudden vision loss in the left eye. Ophthalmological examination showed best corrected visual acuity of 1.0 in the right eye and 0.3 in left eye, with normal anterior pole and intraocular pressure. Fundus examination of the left eye revealed a venous thrombosis in the superior temporal branch, with dilated and tortuous retinal veins. The patient was referred to the hematology unit for thrombophilia study, and was diagnosed with a coagulation XII or Hageman factor deficiency.

DISCUSSION

The development of retinal vessel occlusions, in patients under 50 years of age, is frequently associated with thrombophilia or hypercoagulability disorders. Factor XII deficiency is a rare condition, and its presence could contribute to a higher risk of thromboembolic events.